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Complete this short screening assessment to help our physiotherapy team understand your condition and determine whether BNAP therapy is the right next step for your recovery.
First name
*
Last name
*
ID
*
Gender
*
Male
Female
Prefer not to say
How did you hear about the BNAP Programme?
Employer
Doctor
Friend/ Family member
Social media
Therapist
Other
Language
*
English
IsiZulu
Afrikaans
IsiXosa
Contact number (cell)
*
Contact number (home)
*
Contact number (work)
*
Email
*
Medical Aid
*
GEMS
BestMed
Polmed
Wooltru
Compcare
Massmart
OMSMAF
Tiger Brands
SABMAS
Profmed
Medical aid number
*
Medical aid plan
*
Dependent Code
*
Area of concern
*
Back
Neck
Back & Neck
How long have you been struggling with back/ neck pain
0-3 months
3-6 months
> 6 months
Other
How many of your usual daily activities do you struggle to do now because of this condition?
*
0
1-3 activities
> 3 activities
Have you accessed any medical care/ investigations for this condition in the last 3 months?
*
Yes
No
Please specify
*
X-rays/ scans/ ultrasound
GP
Specialist
Physio/ Chiro/ other
Medication
Surgery
Submit
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